Da Vinci PDex (Payer Data Exchange)

Da Vinci PDex (Payer Data Exchange)

The Da Vinci Payer Data Exchange (PDex) implementation guide defines how payers share clinical and claims data with other payers and with providers using FHIR APIs. It is a core component of CMS's interoperability strategy.

Purpose

PDex enables three critical data exchange scenarios:

1. Payer-to-Payer — When a member switches health plans, the new payer can request the member's data from the old payer
2. Payer-to-Provider — In-network providers can access member data from payers to improve care coordination
3. Member-authorized — Members can authorize sharing of their data between payers and third-party apps

Key Operations

$member-match

Used in payer-to-payer scenarios to identify a member in the source payer's system:

• The requesting payer submits demographic identifiers and coverage information
• The source payer matches the member and returns a unique identifier
• Subsequent data requests use this identifier

$everything

Retrieves a comprehensive bundle of all data associated with a patient/member:

• Clinical data (conditions, medications, allergies, procedures)
• Claims and encounter data
• Coverage information

FHIR Bulk Data

For large-scale data transfers (e.g., payer-to-payer), PDex leverages the FHIR Bulk Data Access specification:

• Asynchronous export using $export operation
• NDJSON format for streaming large datasets
• Supports group-level and patient-level exports

Data Categories Exchanged

• Adjudicated claims and encounter data
• Clinical data (conditions, medications, allergies, lab results, vital signs)
• Coverage and eligibility information
• Prior authorization decisions
• Provider information

CMS Regulatory Alignment

PDex directly supports:

• Provider Access API (CMS-0057-F) — Payers must share data with in-network providers
• Payer-to-Payer API (CMS-0057-F) — Payers must exchange data when members switch plans
• Both APIs must be implemented by January 1, 2027

Profiles Used

PDex extends US Core profiles and adds payer-specific profiles:

• PDex MemberMatch request/response
• PDex Device
• US Core Clinical profiles (Condition, MedicationRequest, Observation, etc.)
• HRex (Da Vinci Health Record Exchange) base profiles for payer-to-payer trust framework